The Humeral Intraosseous Line

By Dr. Sterling

When compared to the proximal tibia site, the humeral site may provide a 5x greater flow rate.


  • Emergent vascular access needed
  • Peripheral IV access cannot be quickly obtained
  • Consider for RSI, cardiac arrest, septic shock, hypotension


  • Recent fracture of humerus
  • Soft tissue infection overlying insertion site
  • Previous attempt at same site within 48 hours
  • Inability to identify landmarks
  • Prosthetic bone or joint

Consider inserting IO elsewhere if patient has osteoporosis or inability to immobilize the limb following IO placement.

Adapted from [5]

Positioning must be in internal rotation and adduction and includes three possible techniques:

  1. Place the patient’s arm in adduction and internal rotation with the hand resting on the umbulicus
  2. Place the patient’s arm in adduction and internal rotation with the hand folded underneath the lower back back (placing the hand under the back may be useful during CPR.
  3. Extend the elbow, while the arm remains adducted and hyperpronating the arm

Adapted from [5]

  • Palpate the greater tubercle of the proximal humerus and then the surgical neck below that landmark. The ideal insertion site is 1cm above surgical neck.
  • IO drill should be placed at 45 with the humeral head. Ensure that you have at least 5mm left of needle length, or it will not be sufficiently long to use.

    • (Blue IO needle that is 25mm will have inadequate length in up to 50% of adult patients)
  • Infusion can be painful so consider the infusion of 40mg (2cc) of 2% lidocaine without epinephrine over two minutes. USE IV FORMULATION FOR LIDOCAINE! Let it sit for 1 minute and then flush with normal saline. If pain persists, then infuse another up to 50% (20mg) of the intial dose in the same way.
  • The first-pass success rate has been reported to be 96%, and the second, 100%2.
  • There is no need to aspirate bone marrow to confirm placement; just watch for extravasation. If you do see extravasation, discontinue the infusion to avoid compartment syndrome and necrosis. IO lines should be removed within 24 hours.
  • Studies have shown safety of infusion of hypertonic saline through IO needles in animal models without tissue damage3, but until those studies have been validated, one should exercise caution.

Here is a video of the procedure:

Edited by Dr. deSouza

  1. Stimac J. Resuscitation and the humeral intraosseous line. EM Resident. 2015 June 13.
  2. Rush SD’Amore JBoccio E. A review of the evolution of intraosseous access in tactical settings and a feasibility study of a human cadaver model for a humeral head approach. Military Medicine. 2014 Aug;179(8 Suppl):24-8.
  3. Pepitas F, et al. Use of intra-osseous access in adults: a systematic review. Critical Care. (2016) 20:102.
  4. Greenstein Y, et al. A serious adult intraosseous catheter complication and review of the literature. Critical Care Medicine. 2016 April 7.
  5. EZIO-ACEP-FactSheet0624c
The following two tabs change content below.


Kings County Hospital | SUNY Downstate Emergency Medicine Resident -Clinical Monster Webmaster

Latest posts by Brian (see all)


3 comments for “The Humeral Intraosseous Line

  1. ablumenberg
    April 25, 2016 at 10:52 pm

    I think IOs are fantastic resuscitation lines — but it’s unusual to use them on adult patients with a pulse. In pulseless patients there’s a lot of activity at the head and trunk, be it airway maneuvers, cpr, monitor placement, etc. One of the advantages of tibial or femoral lines is they utilize unclaimed real estate — a tibial IO can be placed without physically blocking someone else performing another critical task.

    Nice post! I’ll keep this in my mind next resuscitation.

    • iandesouza
      April 26, 2016 at 5:33 am

      For emergent access, if IO access is an option, the femoral line may not be the way to go. Here is a study that compared IO to CVC placement:

      Lee PM, Lee C, Rattner P, et al. Intraosseous versus central venous catheter utilization and performance during inpatient medical emergencies. Crit Care Med. 2015;43(6):1233-1238.

      Mean placement times were significantly shorter for intraosseous than for central venous catheter (1.2 vs 10.7 min; p < 0.001). There were a total of 33 intraosseous versus 169 central venous catheter attempts with fewer attempts on average per patient during intraosseous placement (1.1 vs 2.8; p < 0.001).

      Also, the close proximity of the greater tubercle of the humerus to the heart may allow for more rapid infusion of medications into the central circulation which may be desired for patients in pulseless arrest. And infusion may be better tolerated by patients when compared to the tibial sites (both from unpublished reports).

  2. Anonymous
    April 27, 2016 at 9:27 pm

    Love the humeral site especially when flying in an AStar. The IV tubing port when tibial placed makes access difficult and most times requires getting out of belt. Plus the delivery time is much more rapid.

Leave a Reply

Your email address will not be published.